Introduction

Since the early 1990s, and particularly since the publication of the Institute of Medicine Report, To Err is Human: Building a Safer Health System (Institute of Medicine 1999), the problem of error in medicine and healthcare has received new attention. What had been a silent embarrassment for the healthcare profession – hurting patients who came for care – has been bathed in the light of scrutiny by physicians and others (Leape 1994; Finkelstein et al. 1997). These loyal critics have called for recognition of the difference between a culture of “blame and shame” that has often characterized the treatment of error on the part of healthcare professionals and a culture of organizational learning, one that locates the way to reduce error in the systems and structures designed to produce it.

In this chapter, I argue that many of the lessons learned in the field of medical error can be effectively translated into the area of management error. I begin with a brief summary of the work of two systems theorists. I illustrate some important lessons about medical error by means of a short case narrative, including analysis of it in light of a management policy designed to promote a non-punitive environment for error reporting. Contrasting the “blame and shame” approach with a newer understanding of responsibility for error reduction, I suggest that in both medical and management error, cultural factors play an enormous role.